Renal Replacement Therapy
Acute kidney injury occurs commonly in acutely ill patients and necessitates initiation of renal replacement therapy (RRT) in a subset of patients. Although RRT has been available since the 1950s, despite great technologic improvements in the procedure, t
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Kevin W. Finkel
Acute kidney injury (AKI) occurs commonly in critically ill patients and independently increases morbidity and mortality [1, 2]. Despite impressive gains in the understanding of the basic pathophysiologic principles underlying renal injury, there are no therapeutic options to prevent or ameliorate AKI; treatment consists of supportive care and avoidance of nephrotoxic agents such as radiocontrast and non-steroidal anti-inflammatory agents. At a certain point in the disease course the use of renal replacement therapy (RRT) may be considered. Although RRT has been available since the 1950s, several critical issues regarding the use of RRT remain controversial as outlined in Table 11.1.
Timing of Initiation The classic “indications” for initiating RRT in a patient with AKI are listed in Table 11.2. However, it is misleading to refer to these clinical conditions as indications because it implies that RRT should only be started when such criteria are met. Using such criteria could delay appropriate therapy resulting in serious deleterious effects in critically ill patients. Rather, the conditions listed should necessitate emergent RRT unless only comfort care measures are planned. In the case of lesser degrees of renal injury, the timing of RRT remains a controversial issue. On the one hand, early initiation would certainly avoid the development of any serious complication of AKI; however, the early use of RRT could expose patients to the potential harm of RRT when otherwise they would not have received it (Table 11.3). Currently, there are no randomized controlled trials addressing this issue. Such trials are difficult to perform since we do not have a reliable method to ascertain which patients would
K.W. Finkel (*) Division of Renal Diseases and Hypertension, UTHealth Science Centre at Houston – McGovern Medical School, 6431 Fannin St. MSB 5.134, Houston, TX 77030, USA e-mail: Kevin.w.fi[email protected]
progress to requiring RRT if we avoided “early” RRT and therefore allow proper randomization. Two retrospective studies partitioning patients into “early versus late” initiation groups based on having started RRT when above or below the entire group’s median blood urea nitrogen (BUN) concentration found a survival advantage in the early dialysis group [3, 4]. Although other studies report conflicting conclusions, a recent meta-analysis of all studies to date suggests a benefit to earlier initiation of RRT [5, 6]. Unfortunately, the overall data quality is poor and doesn’t actually outline when RRT should be started. Therefore, initiation of RRT should be individualized to each patient taking into consideration several factors including fluid balance, severity of multi-organ dysfunction, urinary output, age, and co-morbid conditions. For example, an otherwise healthy young person with traumatic rhabdomyolysis and non-oliguric AKI may warrant delayed initiation of RRT compared to an elderly patient with oliguric AKI and multi-organ dysfunction from biliary sepsis that might benefit from earlier RRT.
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